Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries

Abstract

Aims: To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events.

Methods and results: We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6-8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99-1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99-1.12), 1.17 (1.09-1.25), and 1.41 (1.30-1.53) for 8-9 h/day, 9-10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h).

Conclusion: Estimated total sleep duration of 6-8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.

Keywords: Cardiovascular diseases; Mortality; Naps; Sleep duration.

Figure 1

Associations of estimated total sleep duration per day with all-cause mortality and major cardiovascular events. (A) Adjusted for age, sex, and centre as random effect. (B) Adjusted for age, sex, education attainment, smoking status, drinking status, urban or rural residency, family history of cardiovascular diseases (coronary heart disease and stroke), the history of diabetes, hypertension and chronic obstructive pulmonary disease, depression, and centre as random effect. CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio. Incidence: per 1000 person-years.

Figure 2

Restricted spline curve for association between estimated total daily sleep duration and the composite of total deaths and major cardiovascular diseases. Adjusted for age, sex, education attainment, smoking status, drinking status, urban or rural residency, geographic regions, family history of cardiovascular diseases (coronary heart disease and stroke), the history of diabetes, hypertension and chronic obstructive pulmonary disease, and depression.

Figure 3

The effects of nap duration on the risk of the composite of deaths and major cardiovascular events in those with different estimated durations of nocturnal sleep. Adjusted for age, sex, education attainment, smoking status, drinking status, urban or rural residency, family history of cardiovascular diseases (coronary heart disease and stroke), the history of diabetes, hypertension and chronic obstructive pulmonary disease, depression, and centre as random effect. CI, confidence interval; CVD, cardiovascular disease.